The complaint process is used for certain types of problems only, such as problems related to quality of care, waiting times, and customer service. Here are examples of the kinds of problems handled by the complaint process.
Complaints about...
quality
You are unhappy with the quality of care, such as the care you got in the hospital.
privacy
You think that someone did not respect your right to privacy, or shared information about you that is confidential.
poor customer service
A health care provider or staff was rude or disrespectful to you. L.A. Care Medicare Plus staff treated you poorly. You think you are being pushed out of the plan.
physical accessibility
You cannot physically access the health care services and facilities in a doctor or provider’s office.
waiting times
You are having trouble getting an appointment, or waiting too long to get it. You have been kept waiting too long by doctors, pharmacists, or other health professionals or by Member Services or other plan staff.
cleanliness
You think the clinic, hospital or doctor’s office is not clean.
language access
Your doctor or provider does not provide you with an interpreter during your appointment.
communications from us
You think we failed to give you a notice or letter that you should have received. You think the written information we sent you is too difficult to understand.
the timeliness of our actions related to coverage decisions or appeals
You believe that we are not meeting our deadlines for making a coverage decision or answering your appeal. You believe that, after getting a coverage or appeal decision in your favor, we are not meeting the deadlines for approving or giving you the service or paying you back for certain medical services. You believe we did not forward your case to the Independent Review Entity on time.
Call Member Services at 1-833-522-3767 (TTY: 711). Complaints related to Medicare Part D must be made within 60 calendar days after you had the problem you want to complaint about. All other complaints can be filed with us at any time. If there is anything else you need to do, Member Services will tell you. You can also write your complaint and send it to us. If you put your complaint in writing, we will respond to your complaint in writing.
You can make a complaint if we have asked to delay a decision for an appeal. We will automatically give you a “fast complaint” and respond to your complaint in 24 hours. If you are making a complaint because we denied your request for a “fast coverage decision” or a “fast appeal,” we will automatically give you a “fast complaint” and respond to your complaint within 24 hours. If possible, we will answer you right away.
If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, you can request a “fast complaint” and we will respond within 72 hours.
Most complaints are answered in 30 calendar days. If we need more information and the delay is in your best interest, or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total to your complaint. If we do not agree with some or all of your complaints we will tell you and give you our reasons. We will respond whether we agree with the complaint or not.
If you have a complaint about disability access or about language assistance, you can file a complaint with the Office of Civil Rights at the Department of Health and Human Services 1-800-368-1019 (TTY: 1-800-537-7697).
You may also have rights under the Americans with Disability Act and under Title VI of the Civil Rights Act of 1964, the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, all other laws that apply to organizations that get Federal funding and any other laws and rules that apply for any other reason. You can contact the Ombuds Program for assistance.
When your complaint is about quality of care, you also have two choices: If you prefer, you can make your complaint about the quality of care directly to the Beneficiary and Family-Centered Care Quality Improvement Organization (without making the complaint to us). Or you can make your complaint to us and also to the Beneficiary and Family-Centered Care Quality Improvement Organization.
If you make a complaint to this organization, we will work with them to resolve your complaint. The Beneficiary and Family-Centered Care Quality Improvement Organization is a group of practicing doctors and other health care experts paid by the federal government to check and improve the care given to Medicare patients. The phone number for the Beneficiary and Family-Centered Care Quality Improvement Organization is 1-866-800-8749 (TTY: 1-800-881-5980).
You can also send your complaint to Medicare through the Medicare Complaint Form. Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program. If you have any other feedback or concerns, or if you feel the plan is not addressing your problem, please call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048. The call is free.
You can also fill out the Medicare Complaint Form online at the Medicare website.
The Ombuds Program also helps solve problems from a neutral standpoint to make sure that our members receive all the covered services that we are required to provide. The Ombuds Program is not connected with us or with any insurance company or health plan. The phone number for the Ombuds Program is 888-452-8609. The services are free.
For help or more information, contact Member Services by:
Phone: 1-833-522-3767 (TTY/TDD 711), 24 hours a day, 7 days a week, including holidays.
How to Request an Aggregate Number of Complaints (Grievances), Appeals, and Exceptions
You can request an aggregate number of complaints (grievances), appeals, and exceptions filed with L.A. Care Medicare Plus by contacting us. If you request that the information be sent to you in writing, the information will be mailed to you within seven (7) to ten (10) business days.
You can contact Member Services by:
Phone: 1-833-522-3767 (TTY/TDD 711), 24 hours a day, 7 days a week, including holidays.
Fax: Submit written requests to 1-213-438-5748
Mail: Submit written requests to:
L.A. Care Health Plan
Attn: Grievance and Appeals Unit
1200 W. 7th Street
Los Angeles, CA 90017